Identifying facilitators and barriers to culturally responsive communication for racial, ethnic, sexual, and gender minoritized patients when screened for COVID-19 vaccinations: A scoping review protocol

Introduction Racial, ethnic, sexual, and gender minoritized groups are considered historically excluded groups and have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. The influence of social determinants of health (SDOH), including access to screening and treatment, and other systemic and structural factors are largely responsible for these disparities. Primary care practitioner (PCP) competence in culturally responsive screening practices will be critical to reducing the impact of systemic and structural factors serving as barriers to screening and treatment. Correspondingly, improving the capacity of PCPs to communicate with patients in a culturally responsive manner may influence improved screening and treatment outcomes for minoritized groups related to COVID-19. This scoping literature review aims to determine the current breadth of literature on culturally responsive communication (CRC) in regard to COVID-19 vaccination screening for historically excluded, or minoritized groups. Results from this review will inform the development of a training series and social marketing campaign to improve PCPs capacity in CRC. This manuscript provides details on our study protocol. Objectives This scoping literature review aims to analyze existing literature on culturally responsive COVID-19 vaccinations between PCPs and patients in the U.S., specifically for racial, ethnic, sexual, and gender minoritized groups. Results of this scoping review will inform the development of a training series and social marketing campaign to improve capacity of PCPs in this area. Additionally, the review will inform recommendations for future research. Materials and methods This scoping review will be performed following the framework of Arksey and O’Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Relevant studies between the years 2019–2022 were identified using a rigorous search strategy across four databases: MEDLINE (via PubMed), Scopus, Cochrane (CENTRAL; via Wiley), and CINAHL (via EBSCO), using Boolean and Medical Subject Headings (MeSH) search terms. Studies will be uploaded to the data extraction tool, Covidence, to remove duplicates and perform a title/abstract screening, followed by a full-text screening. Results The data extraction and analysis phases of the scoping review are in progress. Data will be analyzed for themes related to culturally responsive COVID-19 screening practices in clinical encounters with the identified study populations. Results will be reported by theme and align to PRISMA-ScR guidelines. Discussion To our knowledge, this is the first study to use scoping methods to investigate the barriers and facilitators to CRC of COVID-19 vaccine screening for historically excluded communities in the U.S. The work and results from this research will be directly utilized for the development of nationally-accessible, continuing medical education materials to teach PCPs about CRC, as well as other materials to influence relevant policy changes within the healthcare landscape.


Introduction
The impact of racism, heterosexism, and transphobia in healthcare settings has been elucidated by the coronavirus disease 2019 (COVID-19) pandemic.People from historically excluded communities, such as those who are racial, ethnic, sexual, and gender minoritized, endure disproportionate systemic barriers and structural inequities related to social determinants that influence increased susceptibility to disease and associated health outcomes [1][2][3].For example, both COVID-19 and human immunodeficiency virus (HIV) are both preventable, communicable viruses that are highly stigmatized and disproportionately affect health outcomes for these minoritized groups [4,5].Culturally responsive communication in the primary care setting for COVID-19 and HIV among these groups may mitigate the negative effects of structural and systemic barriers to care.To promote simultaneous culturally responsive screening for COVID-19 and HIV, our study team aims to design training modules to build PCP capacity in culturally responsive communication (CRC).We are conducting two separate scoping reviews to inform and validate the design of this training, corresponding social marketing campaigns, and policy recommendations.The protocol for one scoping review related to culturally responsive communication for HIV and PrEP has been published with its analysis underway [6].
This protocol informs a scoping review focused on understanding how, and whether CRC is occurring between PCPs and minoritized groups related to COVID-19 vaccination screening.As noted in the aforementioned published protocol, the data from the two reviews will be combined to inform 1) a training series for PCPs pertaining to CRC screening for COVID-19, HIV testing and PrEP screening, 2) a social marketing campaign by PCPs to encourage other PCPs to routinize culturally responsive conversations about testing, screening, and prevention; and 3) a white paper with policy recommendations for improved screening guidelines for HIV and to inform better implementation of current guidelines for HIV, PrEP/PEP and COVID-19 [6].The remainder of this article describes the protocol guiding the scoping review on CRC related to COVID-19 screening by PCPs with the noted minoritized groups.
As there are many intersecting themes between the disproportionate burden of COVID-19 endured by racial, ethnic, sexual, and gender minoritized patients, PCPs should learn to acknowledge the potential differences in culture and perspective when communicating with their patients during the screening of COVID-19 vaccines.This requires PCPs to gain an appreciation for CRC and learn how to facilitate it.However, PCPs may not have the appropriate skills and training to engage in non-judgmental conversations with historically excluded communities about various aspects of care [7][8][9][10][11].
In existing published literature, CRC has been related to culturally competent care and has been defined as "communicating with awareness and knowledge of cultural differences and attempting to accommodate those differences," [12(p2)] and it necessarily involves "respect and an understanding that sociocultural issues such as race, gender, sexual orientation, disability, social class and status can affect health beliefs and behaviours" [12(p2)].Xavier & colleagues expand upon this definition, while emphasizing that within primary care, PCPs must "engage with patients" in a responsive way that appreciates the role of culture, including their views as healthcare professionals [6].According to these authors: "Cultural responsiveness centers unique patient experiences and understandings of health and illness, recognizes the individual biases that clinicians may hold, and seeks to work productively with patients who are not typically represented or valued in the Western understandings of care.At an organizational level, cultural responsiveness includes valuing diversity within the community; institutionalizing cultural awareness; and adapting to best serve the community by creating policies, systems, administrations, and protocols that allow for effective cross-cultural interactions.This type of approach allows healthcare practitioners to work consciously and effectively toward cultivating health equity for historically marginalized groups [6(p2)]".
Correspondingly, CRC could be instrumental in addressing the burden of COVID-19 in historically excluded groups, if we had greater understanding of if and how CRC occurs in patient-practitioner interactions, particularly with minoritized populations.Additionally, current outcome assessments only relate to the influence of cultural competence training on the PCP and on few patient outcomes, such as satisfaction and compliance [13,14].Additional knowledge is required to understand the process, PCP training outcomes, and patient outcomes regarding CRC.
The study team aims to build the capacity of PCPs to routinize CRC in COVID-19 vaccination screening visits.As such, this scoping review focuses on investigating what has been published on CRC between PCPs and historically excluded populations related to COVID-19 vaccination screening.

Disproportionate COVID-19 outcomes
Racial and ethnic minoritized communities are at an increased risk of exposure and burden from COVID-19 due to many systemic disadvantages.COVID-19 disproportionally affects historically excluded communities due to a lack of access to healthcare, racism, gender oppression, structural discrimination, medical mistrust, and more [15,16].Racial and ethnic minoritized patients have about one and a half times greater risk of COVID-19 infection and are twice as likely to die from COVID-19 as their white counterparts when accounting for age differences across racial and ethnic groups [17].In fact, in the summer of 2020, Hispanic people were five times more likely to die from COVID-19, and Black people were three times as likely to die from COVID-19 compared to their white counterparts [17].Endemic inequities are also persistent when it involves income, education, nutrition, transportation, housing, jobs, environment, psychosocial stress, and health care [18].Each of these inequities can be directly tied to the disproportionate incidence, burden, and mortality of COVID-19 for racial and ethnic minoritized people [18].For example, Black Americans are exposed to air that is 38% more polluted compared to white Americans, increasing their propensity for developing asthma as well as their subsequent risk of COVID-19 [19].
Similar to racial and ethnic minoritized groups, sexual and gender minoritized groups face systemic disparities in relation to COVID-19.There is little known on the overall health effects of COVID-19 for sexual and gender minoritized groups due to the limited data collection and reporting executed by the U.S. public health system [20].Despite this, U.S. sexual and gender minoritized people reported having significant and disproportionate poor mental health outcomes due to the COVID-19 pandemic [21][22][23][24][25]. Additionally, sexual and gender minoritized patients reported greater rates of job loss, housing, and food insecurity along with minority stress and stigmatization, all linked to higher levels of mental illness during the COVID-19 pandemic [16,[21][22][23][24][25][26].

COVID-19 vaccination acceptance
Disparities in vaccine access and acceptance are also associated with disproportionate COVID-19 hospitalization and mortality among racial, ethnic, sexual, and gender minoritized patients.By the end of April, 2021, 47% of Hispanic Americans and 46% of Black Americans had received at least one vaccine, compared to 59% of white Americans [27].As of July 6, 2021, only 44% and 41% of Black and Hispanic Americans received a COVID-19 booster dose, while 56% of White Americans received a COVID-19 booster dose [28].Many recent equitybased efforts may have caused vaccine uptake to increase among all racial and ethnic minoritized groups [28].Though vaccine uptake by all groups has recently equalized, it is important to understand the influences on initial disproportionate uptake by racial and ethnic minoritized populations.Additionally, sexual and gender minoritized patients faced initial barriers to receiving and accepting COVID-19 vaccinations with many intersecting themes when compared to racial and ethnic minoritized patients [16].A persistent barrier for COVID vaccinations among sexual and gender minoritized groups include historical and ongoing medical trauma.These barriers, faced by all historically excluded groups, should be addressed in primary care settings.
COVID-19 vaccination acceptance is directly related to psychological behavior, societal and political issues, and vaccine-derived factors that strongly influence decision-making [29].Vaccine-related behavioral patterns are complex and influenced by various extrinsic factors [29].Negative extrinsic factors can accumulate and prevent people from receiving vaccines [30].A major negative extrinsic factor is the behavior of medical mistrust significantly derived from the malicious history of the mistreatment of historically excluded populations in healthcare and medical research [31].In the 1800s, James Marion Sims performed nonconsensual, experimental surgeries on several enslaved Black women without anesthesia [32].From 1932 to 1972, 600 Black men with syphilis were examined without proper consent nor access to penicillin treatments that were readily available [15].In the late 1900s, Black women in Mississippi, who had gone to receive surgeries for their benign tumors, instead had their uterus removed without their consent [15].Doctors in the 1980s falsely referred to AIDS as "Gay-Related Immune Deficiency," kick-starting the stigmatization of HIV and AIDS against sexual and gender minoritized patients [33].These profound historical mistreatments have partly caused the justified mistrust in healthcare among minoritized populations.Medical mistrust could also arise from present-day extrinsic factors that include communication content, communication presentation, policy, and vaccine delivery in clinical settings [34].

COVID-19 vaccination communication and culturally responsive communication
COVID-19 demonstrated the importance of CRC in primary care settings during an emergent health crisis.Throughout COVID-19, the general public relied on varying sources of information to determine COVID-19 vaccine safety and efficacy, some of which are not reliable or evidence-informed [35].This reliance, highlights the central role of PCPs as reputable sources of evidence-informed guidance for their patient populations.PCPs are often responsible for improving health literacy by communicating evidence-based, understandable, and accessible health information to patients [36].Unfortunately, disparate treatment and communication between PCPs and their minoritized patients exists [37].Racial, ethnic, sexual, and gender minoritized patients are significantly more likely to report discrimination, a notable predictor of medical mistrust [15,38].Communication disparities, specifically, are linked to PCP bias and stigma, leading to increased mistrust of healthcare practitioners along with other barriers significantly affecting patient adherence and healthcare-seeking behavior [37].PCPs can better address these current disparities in the clinical setting through our expanded definition of CRC [12].However, we first need to learn more about if and how CRC is currently occurring in PCP encounters with minoritized patients.

Objectives
A scoping review rapidly maps the body of literature on a specific research area and the main sources and types of evidence available [39].Scoping reviews can develop a basis or preliminary understanding of published literature on a topic before conducting systematic reviews [40].This scoping review aims to summarize and disseminate information on CRC between PCPs and racially, ethnically, sexually, and gender minoritized patients related to COVID-19 vaccination.The results of this scoping review will be used to inform future research and policy recommendations to understand and improve PCPs' capacity to routinize COVID-19 screening and prevention with all patients and rely on CRC for patients from historically excluded communities.

Materials and methods
This scoping review will be conducted in accordance with the Arksey and O'Malley methodological framework [39].The framework provides a flexible design for when researchers redefine search terms as familiarity with the literature increases [39].The process is considered to be iterative for researchers to engage with each stage, so that the review is fully comprehensive [39].The framework suggests a scoping review undergo five stages: (1) identify the research question; (2) identify relevant studies; (3) select studies and extract data; (4) chart the data; and (5) collate, summarize, and report results [39].This scoping review will also be guided by the specific steps of the PRISMA extension for scoping reviews (PRISMA-ScR) [41].

Institutional review board statement
This project did not utilize human subjects, nor did it involve a process of informed consent as the need for consent was waived by an ethics committee.This manuscript exclusively provides an overview of a scoping review protocol.The data from this scoping review will be used to inform a continuing medical education intervention that is IRB-approved and supported by grant funding.

Stage 1: Identifying the research question
Before proceeding with the scoping review, the research team first identified pertinent issues while crafting an initial research question to bring forward to multiple clinicians for review and feedback.Most PCPs consulted expressed that there should be a focus on understanding and teaching CRC regarding COVID-19 vaccinations rather than on general COVID-19 prevention and screening.As of now, COVID-19 vaccinations are still not widely accepted in the U.S. despite the compounding positive effects of herd immunity [42].Additionally, minoritized populations are disproportionately affected by COVID-19 due to various systemic and interpersonal barriers described previously.Therefore, the concern for appropriate culturally tailored interventions with COVID-19 vaccination is particularly valid.Correspondingly, the research question (PRISMA-ScR Item 4: Objectives) guiding this review is: "How is culturally responsive communication occurring between patient and practitioner related to COVID-19 vaccination and booster screening for racially, ethnic, sexually, and gender minoritized patients?"

Stage 2: Identifying relevant studies
The search was conducted across the four databases (PRISMA-ScR Item 7: Information Sources) of MEDLINE (Pubmed), Scopus, CENTRAL (Cochrane Central Registry of Controlled Trials), and CINAHL (Complete).Studies with various title-abstract and Boolean and Medical Subject Headings (MeSH) terms pertaining to the research question and definitions of key concepts were included in the search strategy.With input from the research team, collaborators, and an experienced research librarian, an initial search strategy was devised (see Table 1).The search strategy required four categories of terms: terms including the population of interest, terms similar to "culturally competent", terms synonymous to "COVID-19", and terms related to vaccination in the context of the study.
Several groups within historically excluded populations are named in different contexts, languages, and forms.So, it was crucial to include all possible terms that each marginalized group is referred to in scientific literature.For example, each term and all synonyms within the acronyms of LGBTQIA+ and BIPOC were searched.Terms that potentially cause marginalization for groups such as "discrimination", "prejudice", "stereotyping", were also included.All terms related to cultural responsiveness and the practitioner-patient relationship, such as "cultural competence", "cultural sensitivity", and "patient-centered" were included.
As COVID-19 has surged into the global environment, various nomenclature of COVID-19 have also emerged.Studies may have different terminology of COVID-19 due to their scientific nature and specificity of results.Therefore, a thorough identification process of all possible COVID-19 terms was implemented in the search strategy.The differing names include, but were not limited to, "COVID", "n-CoV2", "SARS Coronavirus 2".Search terms specifically regarding vaccination were the last set of terms that had to be included in the search.These terms refer to primary prevention and include "vaccination", "booster", "immunization".The finalized search strategies brought about the following results by database: MEDLINE yielded 284 results; SCOPUS yielded 545 results; CENTRAL yielded 61 reviews and 114 prospective clinical trials; and CINAHL database yielded 127 results.All databases posed problems with formatting and character technicalities.Correspondingly, a few adjustments were made to conduct the search appropriately and reflect searches in other databases.Table 1 provides an overview of the MEDLINE search strategy (PRISMA-ScR Item 8: Search), translated and utilized in the other databases.

Stage 3: Study selection
The scoping review will incorporate two levels of screening using Covidence literature review software.First, titles and abstracts will be reviewed for all manuscripts, and consensus will be required from at least two reviewers for inclusion.All studies deemed relevant in the title and abstract review shall move forward for review in the full-text level of screening (PRISMA-ScR Item 9: Selection of Sources of Evidence).
In the title and abstract review, four investigators (NK, JX, SP, DB) will independently screen each study based on the following inclusion criteria: • Study must be based in the U.S. or analyze a U.S. population (unless it is a scoping or systematic review) • Study must not be a protocol or any type of research not already published.
The search will also be limited (PRISMA-ScR Item 6: Eligibility Criteria) to studies that concern COVID-19 vaccination screening for minoritized populations.Studies will be included if both investigators found that they fulfilled all the requirements of the inclusion criteria.If two investigators have differing opinions on a study, a third investigator will make a final decision on the study's inclusion.The title and abstract review will be conducted by primary reviewers (NK, JX) and secondary reviewers (SP, DB).
Full-text screening of the studies included from the title and abstract review will then be conducted.This stage will require two reviewers to read articles in their entirety and decide whether they should be included in the review.Similar to the title and abstract screening, if two investigators have differing opinions on a study, a third investigator decides if it should be included in the review to be forwarded for data extraction.The relevance and inclusion criteria of the full-text screening will be the same as that of the title and abstract screening.The fulltext screening will be conducted by primary reviewers (NK, JX) and a new team of secondary reviewers (SP, PGC).The resulting studies will qualify for inclusion in the next step of the review, the extraction phase, where data on these studies will be charted.

Stage 4: Charting the data
This stage is meant to collate and synthesize the data in a comprehensive and organized manner to appropriately extract information relevant to our research question (PRISMA-ScR Item 10: Data Charting Process).The extraction phase will be moved from Covidence to Google Sheets to allow for better collaboration and cohesiveness.This study team deemed that Covidence has several limitations when collaborating with group members, copying and pasting from full-text presentations of studies, and selection capabilities.Google Sheets will also allow more flexibility for complicated questions and connectivity between team members.Information from the included studies will be reviewed by 9 reviewers (NK, PLM, PGC, AK, MW, HC, PS, OC, MCW) and extracted through an evidence-based format of prompts and questions requiring a specific input, or checkbox selection, through Google Sheets (PRISMA-ScR Item 11: Data Items).Table 2 reflects our complete data extraction tool.
To increase the rigor of the scoping literature review, 3 primary reviewers (NK, PLM, PGC) will undergo another review of all 81 studies to determine if there was substantial mention of CRC, specifically in regard to direct PCP communication with patients.The 3 reviewers (NK, PLM, PGC) will first extract data on CRC between PCPs and patients from all 81 studies through a similar process as the initial data extraction utilizing Google Sheets.If this information was present in a substantial amount, or in at least one sentence throughout the individual studies, they will be included for data analysis.All results from these reviews will be conducted individually by the 3 reviewers (NK, PLM, PGC) and then be reviewed amongst each reviewer to finalize decisions on what data should be analyzed and what should not.

Stage 5: Collating, summarizing, and reporting the results
Data determined to be useful in answering the study question, "How is CRC occurring between patient and practitioner related to COVID-19 vaccination and booster screening for racially, ethnically, sexually, and gender minoritized patients?"will be collated again via Google Sheets.The data will then be organized by theme and relevance to determine the scope of literature regarding our topic of interest, along with potential gaps in existing literature.The themes and relevance will be identified inductively through emergent coding and then deductively through the lenses of Critical Race Theory [43], Queer Theory [44], and the Socio-Ecological Framework [45].These perspectives stress the importance of centering the voices of minoritized patients in order to understand, disrupt, and reshape systems of power, as these groups are best able to speak to their humanity and experiences.The scoping literature review will also focus on identifying the breadth of the available literature rather than its quality, which is typically evaluated through a systematic literature review [40].After analysis, results will be synthesized and reported according to PRISMA-ScR guidelines (Item 13: Synthesis of Results; .The process used to select studies will be detailed in a PRISMA flowchart (PRISMA-ScR Item 14: Selection of Sources of Evidence).The study team will disseminate our findings of the scope of available literature, as well as opportunities for future research and clinical interventions in regard to CRC for COVID-19 vaccination screening in primary care settings.

Discussion
As minoritized patients often face many barriers to health care, PCPs must aim to be trusted sources of information through utilizing CRC to facilitate important discussions with minoritized patients about COVID-19 vaccinations.Discussions incorporating CRC are vital in influencing a patient's decision-making process when considering to take a COVID-19 vaccination or booster.This scoping review will indicate if and how CRC is currently implemented in PCP encounters with minoritized patients.To our knowledge, this is the first study to use scoping methods to investigate the barriers and facilitators to CRC between PCPs and minoritized patients regarding COVID-19 vaccine screening.This scoping review protocol will allow us to adequately map the landscape, gaps, and prominent themes of current research.Our findings will then be disseminated in publication and via nationally-accessible, continuing medical education materials, as well as other materials to influence relevant policy changes within the healthcare landscape.One limitation involved the translation of search terms of interest across databases in the health and medical sciences.Each database has unique language parameters and search requirements, resulting in minor differences across databases.

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Study must conduct research for or with an LGBTQIA+ and/or BIPOC group • Study must include any results and/or discussion related to COVID-19 vaccines • Study must include attitudes, behaviors, etc. of patients and/or PCPs in healthcare settings • Study must have been published after November 2019 (start of COVID-19)